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Cholecystectomy

and
Partial Cholecystectomy

 Extensive adhesions. . CHOLECYSTECTOMY FROM FUNDUS DOWNWARD INDICATIONS  Cholecystectomy from the fundus downward is the desirable method in many cases of acute or gangrenous cholecystitis. or a large calculus impacted in the ampulla of the gallbladder makes this the safe and wiser procedure. thick-walled.  Better definition of the cystic duct and cystic artery is ensured with far less chance of injury to the common duct. Some prefer this method of cholecystectomy as a routine procedure. acutely inflamed gallbladder. where exposure of the cystic duct is difficult and hazardous. a large.A.

a mounting white cell count. Antibiotic therapy is given. Constant gastric suction may be advisable.PREOPERATIVE PREPARATION  Early operation is indicated in patients seen within 48 hours after the onset. . or an increase in the signs and symptoms suggesting a perforation.  Regardless of the duration of the acute manifestations. as soon as fluid balance and antibiotic coverage have been established. surgical intervention is indicated if there is recurrence of pain.  Frequent clinical and laboratory evaluation over a 24-hour period is necessary.

Such patients require operation as an “off-schedule” urgent procedure. The gallbladder may show advanced acute inflammation despite a normal temperature and white count and negative physical findings. . especially if they have diabetes mellitus.  Approximately one patient in five with acute cholecystitis will not progressively improve and may worsen.

 In elderly or debilitated patients. although some type of analgesia is usually necessary as a supplement at certain stages of the procedure .ANESTHESIA  General anesthesia with endotracheal intubation is recommended. may be used in preference to general anesthesia.  Spinal. local infiltration anesthesia is satisfactory. In those patients suffering from extensive liver damage. either single-injection or continuous technique. Deep anesthesia is avoided by the use of a suitable muscle relaxant. barbiturates as well as other anesthetic agents suspected of hepatotoxicity should be avoided.

.POSITION  The patient is placed in the usual position for gallbladder surgery. . the position may be modified slightly to make the patient more comfortable.  If local anesthesia is used.

.OPERATIVE PREPARATION  The skin is prepared in the usual manner.

INCISION AND EXPOSURE  Two incisions are commonly used: the vertical high midline and the oblique subcostal  The omentum must be separated carefully by either sharp or blunt dissection from the fundus of the gallbladder. . An oblique incision below the costal margin is preferred. care being taken to tie all bleeding points. especially if the mass presents rather far laterally.

 A short incision is made through the serosa of the fundus. A fenestrated forceps is introduced deep into the gallbladder to remove any calculi in the ampulla. or to proceed with the retrograde cholecystectomy.DETAILS OF PROCEDURE  The appearance of the fundus and the patient’s general condition determine whether it is safer to drain the gallbladder or to remove it from the fundus downward.  Blunt dissection only is utilized to free the omentum and other structures from the gallbladder wall. It is safer to empty the contents immediately to decrease the bulk and to give more exposure. and the liquid contents are removed by suction. a trocar introduced. Cultures are taken. which prevents further soiling and serves as traction . The opening is closed with a pursestring suture.

Separation is accomplished by blunt or scissors dissection. excessive traction will result in avulsion of the gallbladder from the liver bed.An incision is made into the serosa of the gallbladder with a scalpel along both sides about 1 cm from the liver substance otherwise. especially since the loose tissue beneath the serosa is edematous in the presence of acute cholecystitis .

a gallbladder is further freed by scissors dissection relatively dry field is obtained if the cuff is closed with interrupted sutures as the dissection progresses down to the ampulla . half-length clamp.The cuff of gallbladder serosa in the region As the cuff at the margin of the liver is of the fundus is held with forceps. while the held by a curved.

The cystic artery and adjacent tissues choledochostomy is not indicated. It is safer to isolate the cholangiogram showed clear-cut the cystic artery as near the gallbladder wall as evidence of a calculus there. The artery may be much larger overlooked. cystic duct is divided between right-angle angle clamp and ligated.. and exploration is avoided unless be in an anomalous position. If possible. especially if acute cholecystitis is present. and the right hepatic artery may carefully. the are divided between a half-length and a right. The cystic artery is isolated with any The cystic duct is palpated carefully. The common duct is palpated than normal. accompanying to ensure that a stone has not been indurated tissue. and half-length clamps and tied unless a cholangiogram is planned through the cystic duct .

PARTIAL CHOLECYSTECTOMY  If a classic open cholecystectomy appears hazardous because of advanced inflammation. . or if structures in the cystic duct region cannot be safely identified.B. the full thickness of the gallbladder is left within the liver bed. or if the gallbladder is partially buried in the liver.  A very specific indication for this procedure occurs in patients with cirrhosis of the liver and portal hypertension.

Attempts to remove the back wall of the Calculi impacted in the ampulla or cystic gallbladder will result in significant hemorrhage duct are removed with fenestrated that can be extremely difficult to control. The gallbladder is aspirated. and traction is exerted forceps on the fundus. which may be densely adherent to the adjacent structures . The inferior surface is divided cautiously down to the ampulla.

If the cystic duct can be intubated with a small catheter (figure 9). The Silastic drains are withdrawn beginning 7 to 10 days after surgery. a cholangiogram may be performed. Fortunately. . the spiral valves in the retained cystic duct stump usually scar shut. Often the gangrenous cystic duct cannot be found and Silastic closed suction system drains are placed in the general region of the duct as well as in Morison’s pouch.The mucosa in the retained portion of the gallbladder head is destroyed by electrocoagulation. depending upon their output.

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